Provider Demographics
NPI:1225092000
Name:DINEZZA, GARY JAMES (PHD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:JAMES
Last Name:DINEZZA
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 GOODRICH ST
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14203-1005
Mailing Address - Country:US
Mailing Address - Phone:716-859-2119
Mailing Address - Fax:
Practice Address - Street 1:80 GOODRICH ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14203-1005
Practice Address - Country:US
Practice Address - Phone:716-859-2119
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-17
Last Update Date:2022-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011753103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RA1894Medicare ID - Type Unspecified
R53740Medicare UPIN